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Johnson-Alloway, M.D., Instructor in Gynsooology, MoGill University ; Assistant Surgeon to the Montreal General Hospital ; Gynaecologist to the Montreal Dispensary. {Read before the Canadian Medical Association, at Ottatoa, September, 1888.) Mr. President and Gentlemen^ — To Marion Sims uterine surgery owes its birth, and to the genius of such men as Emmet on this continent and Schroeder in Europe it is indebted for its advancement to a high position in surgery. And it does not therefore seem strange that the names and energies of these two latter gentlemen should be associated with a certain definite morbid condition of the cervix uteri in their respective methods devised for its relief. There is not a procedure better known, or one on which there has been more written, than Emmet's trachelorrhaphy. Indeed it has, in the past, occupied so much attention in our local socie- ties and medical journals, that at present the majority of us are feeling somewhat inclined to give it a little gentle rest. It is on this continent, however, that it has substantially flourished, but even here, Noeggeroth, after adopting ic as part of a lifetime's work, tells us in his declining years of pensionhood that it is not at all necessary. But, gentlemen, we must not mind this strange and unnatural reversion of opinion under such circumstances ; the present generation of uterine surgeons has experienced of * Clay models of operations were exhibited. late another example of such reversion of opinion under similar circumstances. In England and France, the non-appreciation of Sims' specu- lum has conduced to perpetuate a feeling of conservatism which we look upon as being so inimical to the advancement of scien- tific uterine surgery, and which has accounted, in a measure, for the lukewarm acceptance of the benefits of trachelorrhaphy in these countries. In Germany, however, Simons' perineal retractor has opened up to these original investigators a vast field of information in regard to operations upon the uterus. And what Sims' instrument did in America towards making possible operations upon the uterus through the vagina, Simons' instrument led the way to similar work in Germany. To the respective merits of these two instruments, as perineal retractors, do we owe the recent advances made in uterine surgery towards the alleviation of much suffering otherwise inseparable from the function of reproduction. I have introduced in a passing way the application of these two perineal retractors, because I think the advantages which Simons' instrument has over Sims' in operations upon the cervix should be considered. One of the principal advantages consists in the all important fact, that with Simons' instrument we can render more easily the vagina purely aseptic before the operation has been begun, and carry it out under a con- tinuous stream of sterilized water. When I first began to perform trachelorrhaphy it was not thought necessary to do anything further than clear away obstructir ' mucus, and even at present in some large centres, sterilizing jf the passages is delegated to the hospital nurse, prior to the patient being placed on the operating table. Dr. Brooks H. Wells, of New York, has shown by a carefully-prepared statistical table that in the practices of fifteen of the most eminent specialists in America, no less than 43 cases of pelvic imflammation and 6 deaths had occurred following the performance of so simple an operation as trachelorrhaphy, and surely so appalling a record should cause us to pause and enquire for a cause. Imfiam- ^ I .» mation following operations upon the cervix are by some attributed to traction upon the pelvic floor, but this I look upon as a myth, and can accept but one real cause — infection from without, I do not believe there is ever sufficient traumatism produced in connection with operations upon the cervix to set up inflammatory action either in the wound itself or in the parametral tissue adjacent to it. In considering the indications for an operation upon a lacerated and otherwise diseased cervix I will not take up time with the matter, the full digest of which we are all here acquainted ; but I would like, sir, to lay before yourself and the gentlemen present the consideration of a few ideas which have originated during careful thought, in my endeavour to improve wherever experience prompted the necessity for such improvement. It is in this way only that we can obtain com- parative evidence of sufficient value to enable us to draw logical conclusions. In regard to trachelorrhaphy for lacerated cervix, I found after I had done many cases that so long as I had to deal with a simple ununited cervical wound, free from areolar hyperplasia, displacement, chronic parametritis and perimetritis, chronic endometritis with cervical catarrhal patches, and other pathological conditions accompanying such a lesion, a simple trachelorrhaphy after Emmet's method produced the most promising results. And many of such simple cases were found lo have been ladies who werri told by their physician that they had a slight tear in the neck .of the womb, and that if they took rest 'v\ bed, hot water douches and other palliative methods of treatment they would get better of their pains, and that eventually they could bear an operation done at some more convenient time. No better advice could possibly have been given, and no better course of treatment could have been carried out. In fact, all the good had been done by the patient's family physician, and the special surgeon found a patient, as a supplicant to him, to do a certain operation upon her cervix. Then, again, we meet with cases which are of recent origin, that is from six to twenty months after delivery, and where the principal symptoms are reflex neuralgias, extreme 6 debility and hemorrhagic endometritis. In these cases it is only necessary to readjust the torn edges of the cervix and enforce the necessary rest to favor more complete involution. These latter patients sometimes became neurasthenic, take on st>*ange hallucinations, think they have heart disease, cancer, ovarian, or some obscure disease with which they say we are not familiar, and therefore, from which they can get no relief. Trachelorrhaphy sometimes acts like a charm upon the mental condition of such patients, but occasionally altogether fails, or even places them in a worse state. To repair the cervix here, however, is quite right, but the recovery of such a patient depended more upon a form of treatment outside of our present theme. These few broad illustrations, gentlemen, of the more fre- quently met with cases wherein Emmet's method of simply restoring the cervix to its original form, will partially serve our purpose in my endeavours to show the leading indications for that procedure. ■ We will now, gentlemen, pass on to consider another morbid condition of the cervix very often associated with laceration, wherein Emmet's operation does not succeed in giving relief. In this class of cases we have extensive catarrhal disease of the mucosa, with ectropion ana general hyperplasia of the injured tissues. Schroeder claims that the catarrh does not depend upon the laceration, but the reverse — that the laceration is due to the catarrhal disease. I am inclined to think that Schroeder is, to a certain extent, undoubtedly right. Catarrhal disease must tend to destroy the integrity of the elastic properties of the cervix, and also to prevent union of the torn tissues during the puerperium. Again, how frequently do we meet with cases of most extensive catarrhal disease in women who have never been pregnant, and we sometimes see the catarrhal patch occu- pying the whole of the portio-vaginalis, extending as far back as the vaginal junction. So that, given, a case of bilateral lacer- ation, extensive ectropion, chronic catarrhal inflammation of the endometrium, formation of retention cysts, and connective tissue hypertrophy, I say that Emmet's trachelorrhaphy is incorrect 1 I- i 1 ! and unsuitable, and will not give relief. The reason why the operation is unsuitable to such a case is very obvious, and can be explained in this way. Wo have an extensive catarrhal hypertrophy of the mucosa of the whole orvical canal, the cylindrical epithelium often being replaced by pavement, and there is extensive formation of retention cysts. Now this con- dition affects the central portion of the canal wall principally, and the mere paring of the torn edges and bringing them together with sutures will in no way cure the catarrhal disease of the central strip left on each cervical segment. And I have found that the tension is so great on the sutures that the lower ones invariably tear out and allow a certain degree of ectropion again to take place. There are other interesting points in the pathology of cervical lacerations recently brought forward by Bandl. He found that in 130 post-mortems on women who had borne children, 76 showed well-marked inflammatory residues in the parametral surroundings of the cervix, and that these cases also bore evi- dence of cervical lacerations. It can also easily be understood that the constant endeavor on the part of nature to heal the injured part during the puerperium would tend to kov. ^ up a venous congestion, leading to increased growth of connec- tive tissue ; and in this way we get inflammatory remnants in the parametral tissue surrounding the cervix following laceration. These inflammatory remnants are also found affecting the peri- toneum, causing displacements of the uterus of a most intract- able kind to treat. In the case of a heavy bulky uterus descend- ing low down in the pelvis, and, when uncomplicated by inflam- matory remnants, becomes retroverted by virtue of the long hyphertrophied cervix being driven against the posterior wall of the vagina, and is reflected forward and downward, causing the fundus and body to be thrown backwards. In such cases I have found the truth of this mechanism of retro-displacements in the fact that after the removal of the cervix, the uterus did not be- come retroverted, and therefore did not require a pessary. I do not mean, however, that those aggravated cases of prolapse with a retroflexed uterus jammed low down in the well of the \ 8 \ pelvis should be confounded with the cases in point — they require other additional methods of treatment. On considering all these facts, and the unsatisfactory results following Emmet's operation in certain such cases, it occurred to me that some procedure more radical in character must be done so that we may reduce the size of the uterus and cut off some of its abnormal blood-supply. To- wards this end, exsection of the whole of the diseased mucosa and sub-mucous tissue suggested itself to me in the form of what is known as Schroeder's operation. This operation consists in split- ting up the cervix on each side to, or past, the vaginal junction, as circumstances may indicate. Then a transverse incision is made across the base of the flap, just below the internal os ; this in- cision should go through the mucous membrane well into the fibrous wall of the cervix. With a long, sharp-pointed, straight bistoury the centre of the segment is transfixed from its point to the transverse incision at its base. The wedge-shaped piece thus lined out is removed and the flap remaining turned in over the stump by silkworm gut sutures. The same is done with the other segment of the cervix, and one suture is passed through the angles on each side. The wound is now dressed with absorbent cotton saturated with 1 to 40 carbolic acid in glycerine, and dusted with hydronaphthol. This dressing is allowed to remain in situ for six to eight days, when it will be found quite aseptic. The sutures are removed on the tenth day. I may here, in passing, say that I always curette the walls of the uterus with the sharp instrument and use the steel dilators on the internal os, if necessary, to secure good drainage. I rarely use vaginal injections, as, if at the outset we make the vagina aseptic, and carry on the operation under sterilized hot water, we need have no fear of after decomposition of the fluids. I have now performed Schroeder's operation upon the cervix in 15 hospital and 22 private cases, and have not known a single rise of temperature or other untoward symptom follow the operation. The after results have been so gratifying, over and above what I had before received from Emmet's method, that I will continue to discriminate and perform it in all suitable cases. ^S ^